By Dave Gardener
Within America’s vast $3.65 trillion health care system, teams of specialized caregivers are striving to tend to the needs of both mind and body, with an eye on challenges as well as opportunities.
A wide variety of high-tech equipment from the world of science lines the halls at Northeast Radiation Oncology Centers (NROC), but survivorship issues and quality of patient life are also vital within treatment, according to Christopher Peters, MD, medical director. Access to a dietitian, exercise therapists and care for the mind are all vital parts of this formula.
According to Dr. Peters, each patient’s situation is different as his or her treatment plan unfolds. This amplifies the fact that caregivers apart from physicians can help a patient in ways that a doctor can’t.
“We have followed this comprehensive approach with care this since day one of the center opening,” said Dr. Peters.
He described how problems with body image often haunt cancer patients during and after treatment, making support groups and a shared commonality helpful as social relationships develop. Caregiver staff members can also participate in care associated with patient emotional needs.
“Therefore, the push for survivorship and quality of life during post-diagnosis treatment is national in scope,” said Dr. Peters.
Nutrition counseling is a vital part of oncology treatment, according to Mary Klem, registered dietitian with a board certification in oncology. She described how the side effects of cancer treatment can be difficult for a patient in regard to eating, resulting in needs for specially textured foods and fiber contents that must be changed according to the onset of various symptoms.
Oncology dieticians are also finding themselves in a nation-wide battle against misconceptions about the best way to deal with cancer. Patients often wind up limiting nutritional items that are important within their recovery, or abusing supplements.
“A non-science approach that obtains ideas from the internet is not the best source for information,” said Klem. “Sometimes I think whoever writes these things is selling something.”
She emphasized that oncology dieticians can’t “heavy hand” a patient with nutritional advice, particularly if the individual is suffering from additional sickness from treatment. Yet, portion size and texture for swallowing all are vital for compliance with a care plan, and losing weight is certainly favorable for most patients.
On a positive note, Klem has noticed that most people she deals with seem to be increasingly interested in nutrition. They also grasp that simple fresh food within any dietary plan is always a plus.
“Sometimes, simple techniques such as setting up a crock pot before you leave for work can make very big changes in what we are eating,” said Klem.
Renewing the relationship between a cancer patient and his or her body is the work of former Olympic rower Abby Peck, MA, exercise and sport science specialist with NROC. She detailed how cancer treatments often bring physical and emotional pain that can be highly emotional to endure, thereby disrupting the mind-body partnership.
“We work with these patients despite their limitations and help them to use their bodies in a positive manner,” said Peck. “We also laugh a lot, even though this is all happening while so many are dealing with pain.”
A Peck-coached workout utilizes exercise routines, cardio work, weights and sessions with other types of equipment. An additional patient benefit she observes is the uplift often felt from simply being at NROC with fellow patients, as well as interacting with living examples of people beating the disease.
“Any cancer patient can come here and participate,” said Peck. “They don’t have to be in treatment with NROC.”
Patient motivation within oncology varies widely, thereby making it important to encourage the behavior known as mindfulness. This involves attention to the way a person thinks and acts, with the promotion of inner peace.
In the cross hairs of the battle to tend to these mental health needs strives NROC’s Mindy Mordan Hill, certified wellness and yoga therapist. Yoga is her lifelong passion as it is utilized to calm the mind, emphasize the miracle of breathing and create spiritual connections.
Hill interacts with more than 100 patients each week within her yoga classes. The physical activities also teach patients to combat anxiety and encourage their ability to sleep which is vital for healing.
“Medical practices, to some degree, have their hands tied in what they can offer,” said Hill. “But, oncology caregivers all know they need to provide people with the tools for wellness if they are to thrive, and that’s where we come in.”
She added that patient compliance is never a problem with Yoga, and that some patients, after their recovery, continue with yoga due to the ongoing health benefits. This includes a reduction of aches and pains, lower blood pressure and mental serenity.
“This is all part of society’s shift to acceptance of the vital need for wellness,” said Hill.
Home care productivity
As the need for home health care increases, administrators within the medical specialty are dealing with challenges such as rising demands for caregiver productivity plus cost effectiveness. Additionally, as the number of elderly Americans explodes, needs for home care are sure to also accelerate.
Melissa Kelleher, assistant vice president of Home Health with Allied Services, manages a program that has been serving a wide variety of post-acute patients for more than 30 years. The staff, exceeding 65 employees includes skilled nursing personnel plus physical, occupational and speech therapists, as well as care aides you may help patients with tasks as basic as bathing.
As private insurers push for cost savings with care, the goal of Allied to return patients to self-care becomes increasingly attractive. The staff, within an average year, cares for more than 2,000 patients and any given time must deal with 260 to 280 patients on its active census.
According to Kelleher, 60 percent of the care is paid for within Medicare advantage plans, plus a limited amount of Medicaid coverage. Constant regulatory changes must be coped with, and during 2020 payment systems are scheduled to shift away from pay-per-episode to a Patient-Driven Groupings Model (PDGM).
The PDGM system, according to its proponents, will focus on patient needs. It also will rely more heavily on patient characteristics in order to pay for home health services.
As Allied faces this financial conversion, a nagging problem sure to continue involves staffing shortages. Kelleher commented that Allied has been lucky due to its maintenance of a stable workforce with longevity, but it is increasingly difficult to recruit nurses, particularly weekenders and those working on-call.
“Many of the kids who choose to study nursing continue in their schooling and go on to become a nurse practitioner,” said Kelleher. “One of the reasons for this as that they will be carrying heavy educational debt upon graduation, and therefore need the higher salary of a nurse practitioner.”
She also explained that, as the elderly numbers in the country rise, more nurses than ever before will be needed. The nation’s schools can only turn out so many graduates, ensuring that workforce shortages will compound.
“I have no idea how we’re going to deal with any of this, and its all part of the reality that home health agencies must evolve, be part of a system acquisition, or close,” said Kelleher.
Allied’s home care nurses are each required to “see” six patients per day to satisfy productivity requirements. Within the home environment the requirement for extensive computer documentation of each patient’s situation can also be difficult, because time spent on an iPad is not the hands-on care nurses are expected to deliver.
“Payment and quality control all depend on accurate documentation, so there’s no way to reduce the amount of computer time our nurses must spend during each home visit.” said Kelleher.
Vital services such as primary care, behavioral health and the need for social assistance for mothers-to-be who are within the grasp of addiction are all being addressed within the Healthy MOMS program.
Maria Kolcharno, director of addiction services with The Wright Center for Community Health, administers the substance-related portion of the program. She declared that opiates remain the number one problem in NEPA, with some alcohol and cocaine treatment also needed.
Working within the behavioral health services of the Wright Center, Healthy MOMS functions with a keen understanding that without resources and life skills, the situation facing a pregnant woman can be daunting. When addiction is present, the scenario can become overwhelming.
The program’s caregivers therefore strive to take down barriers that inhibit addicted women from receiving vital services by utilizing a collaborated network financed with government grants. The driving force behind the effort, according to Kolcharno, is Linda Thomas-Hemak, MD, president and CEO of The Wright Center for Community Health.
“Addiction treatment resources are limited even within a 12-step program, and there’s way too much simplicity out there even with drug treatment, such as the 1980s ‘Just Say No’ initiative,” said Kolcharno. “We’re very aware that future sustainability of a program like ours is always a problem, even though many doctors and clinics are not necessarily positioned to deal with these types of social problems.”
Patients come to Healthy MOMS through various paths such as billboard and radio advertising, prison referrals, personal networking, Maternal and Family Health Services and the Wright Center as a patient. Kolcharno has noted that most pregnant moms are usually compliant because they fear hurting their child, and agree to use the drug Subutex to reduce cravings and opiate withdrawal symptoms.
The program then teaches the women to focus on the problems at hand and learn life skills, financial planning and to integrate behavioral modifications into their lives. Instruction in money management skills are also offered, as well as day-care options and how to pay for it.
According to Kolcharno, the program formally launched in October of 2018, and as of mid-May 40 expectant mothers had “enrolled” with 17 births. Healthy MOMS is also working with the maternity staff at Commonwealth Moses Taylor to break down the stigma of addiction and include more women in birthing classes.
“Some addicted women, to counteract the stigma they feel, will simply do an emergency department birth,” said Kolcharno. “Guilt and shame are also big factors with these mothers, and they have fears that the government will take their baby away.”
The program also creates a safe care plan for the post-birth era. The participants are fully informed about the societal realities they will face, and drug screened.
“Once the word ‘baby’ is mentioned, most people in this society are open to helping moms-to-be,” said Kolcharno.
The evolving science of DNA exploitation is alive and well within the Geisinger Health System with the expanding MyCode Community Health Initiative. This program identifies genomic variants within consenting patients that increase the risk of a specific diseases, such as heart disease, cancers and cystic fibrosis.
David Ledbetter, Ph.D, executive vice president and chief scientific officer, explained that more than 235,000 patients have signed consent forms that allow the program to draw their blood and subject it to select genomic testing. More than 145,000 of these samples have now been DNA sequenced, creating the largest study of its kind in the world.
According to Dr. Ledbetter, the initial findings of 100,000 adults in average health with sequenced genomes indicate two percent have genetic variants that create a real risk for the serious diseases being identified. In addition, one-half this group has no recorded family history that would lead to testing for the diseases.
“This means that 50 percent of the group would have waited until symptoms appear, which is certainly not preferable,” said Ledbetter. “This is encouraging to us and gives us the power to help them before disease appears.”
He indicated that the future of MyCode will include expansion of the number of genetic variances being identified that cause disease. In addition, DNA sequencing costs continue to drop.
According to Ledbetter, identification of a genetic variant that causes disease can have an emotional side-effect for a patient. However, the vast majority of program participants react well to the news of high risk, and then pursue a better outcome for their situation.
“There also are some conditions that may have genetic variants which we are not testing for because of a lack of effective prevention,” said Ledbetter. “These include Alzheimer’s and Parkinson’s.”